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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 200 RALEIGH TAVERN LANE 11/1/2021 Commonwealth of Massachusetts City/Town Of North Andover System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health.Other forms may be used,but the information must be substantially the same as that provided here.Before using this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1. System Location: 200 Raleigh Tavern Lane Address North Andover MA 01845 City/Town State Zip Code 2. System Owner: Debra O'Brien Name 200 Raleigh Tavern Lane Address(if different from location) North Andover MA 01845 City/Town State Zip Code 9783140032 Telephone Number B. Pumping Record 1. Date of Pumping 09/21/2021 __ 2 Quantity Pumped: 1500.0000 Date Gallons 3. Component: ❑Cesspool(s) © Septic Tank Tight Tank Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ©Yes❑ No If yes,was it cleaned? ©Yes No 5. Observed condition of component pumped: sludge. Butli baffles are intact. Matn line electr. Filter is present and ticis been cleaned as needed. over s secured. Recommended Boost additive,CCLS additive. 6. System Pumped By: Michael Graham Name Vehicle License Number Wind River Environmental, LLC, 577 Main Street, Ste #110, Hudson, MA 01749 Company 7. Location where contents were disposed: Greater Lawrence Sanitary District 240 Charles Street , North Andover, MA 09/21/2021 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1